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Interactive cases in pressure ulcers
WORLD UNION OF WOUND HEALING SOCIETIES CONFERENCE
the incidence of non-blanching erythema in a hospital in-patient population (n=23) when compared to the use of the ninety-degree lateral and supine position (n=23). The main findings were that patient positioning using the thirty-degree tilt method did not reduce the incidence of non-blanching erythema compared with either the ninety-degree lateral and supine positions. This study also investigated the feasibility of using the thirty-degree tilt position and identified that subjects experienced difficulty in adopting and maintaining the position. This finding seriously questions the practicality of the thirtydegree tilt method when it is used with a predominantly ill population. The problems encountered in conducting research in the clinical area are highlighted.
Physiological and anatomical indications in pressure ulcers ns. Bain ( Given the validity and reliability problems entailed by risk assessment, a promising adjunct strategy for reduction in ulcer prevalence is offered by diagnostic tools for early identification of incipient ulcers. In current clinical practice, grade 1 pressure ulcers are unreliably diagnosed. Problems include the difficulty in seeing and comparing erythema in different skin types, especially in dark skin, and the variability in subjective assessments. Three approaches for detecting the early signs of pressure ulcers are considered: 1) An objective measurement device based on reflectance spectroscopic principles that examines the volume, oxygenation, and dynamics of blood in the skin. 2) Using NMR parameters to identify early changes taking place deeper in the tissue. 3) Nutritional and biochemical markers. An objective device for assessment of skin condition has the potential to enhance reliability of clinical judgement. This is useful for consistent early identification, and steady tracking of progress, botl1 of which are key to effective management of grade 1 ulcers.
Wound dressings S. Bale The effective use of dressings results from a structured, systematic and logical approach to patient care. This organised approach comprises assessment of patient's needs, the formation of a wound care plan, selection of an appropriate dressing, and evaluation of progress. Assessing patient's needs: Factors that impair the healing process including intrinsic and extrinsic factors; Wound assessment including wound bed, exudate level, wound shape, and wound size; Patient's preferences including lifestyle, ability to work and desire to become involved in wound care; Patient's circumstances including physical environment of home or hospital. Formulating a wound care plan: Investigations needed including Doppler, Xray, blood values and risk assessments; Interventions indicated including wound debridement, cleansing, and
22
compression bandaging. Select a dressing based on these criteria: Alginates; Hydrocolloids; Foams; Hydrogels; Low adherent dressings; Medicated dressings. Evaluate progress: Wound measurement; Charting wound bed health; Time to healing. The aim of this workshop is to demonstrate the role of dressings in managing wounds.
Palliative care S. Bale Carcinomas and sarcomas are the most likely cancers to produce ulceration and fungation in the later stages of the disease. Managing patients with these malignant wounds often presents difficult clinical challenges. The most common type of ulcerating or fungating lesion is' found in women with breast cancer. As the prognosis for healing is usually poor, symptom control and improvement in quality of life are frequently the main aims of care. Managing patients with such complex problems requires a multidisciplinary approach, and typically this team includes the nurse, oncologist, psychologist, and surgeon. It is also important that the patients are encouraged to identify their main problems and that subsequent interventions are decided through a partnership between the clinician and patient. The aim of this workshop is to discuss the care of patient's with complex clinical malignant wound problems. It is important to determine, through a comprehensive assessment, the treatment aims. This usually comprises control of symptoms such as odour, exudate, pain, and also body image. These problems can occur in combination, where wounds are highly exuding, malodorous, bleed easily, and can cause pain' and discomfort. Effective wound management includes the skilful use of dressing materials to cope with the physical problems of odour, bleeding and excess exudate, although the psychological problems are more difficult to deal with.
Nutrition and wounds M. Clark Poor nutrition has often been associated with both pressure ulcer prevention and healing and attention to nutrition is often proposed within pressure ulcer clinical guidelines. However what is the evidence that impaired nutrition increases the likelihood of developing pressure ulcers? This presentation will consider the evidence that impaired nutrition is directly associated with the development of pressure ulcers. The presentation will also consider the limited evidence that improving nutrition can reduce the incidence of pressure ulcers.
Interactive cases in pressure ulcers C. Dealey Management of pressure ulcers can be complex and challenging. It requires a multi-professional approach, particularly for patients who remain at risk of further
VOL 15 NO.2 MAY 2005
pressure ulcers development after the existing ulcer is healed. It is important to identify the causative factors for a pressure ulcer so that they can be removed wherever possible. Management strategies should include a holistic assessment, pressure relief, nutrition, skin care and wound management. Workshop participants will be presented with a number of cases and will be invited to discuss their management.
Epidemiology of venous ulceration P. J Franks Current prevalence estimates of chronic leg ulceration are frequently based on studies undertaken during the 1980's. During the last decade, major changes have occurred in the application of evidence based practice, potentially altering the prevalence and patient characteristics of this group. We have determined the prevalence and aetiology of leg ulceration in a defined geographical population with eight years experience of providing a standardised evidence based protocol of care. Identification, interview and clinical assessment of patients with leg ulceration (>four weeks) within an integrated acute and community leg ulcer service were undertaken. Standardised questionnaire on medical history, ulcer details and non invasive vascular investigation were used to describe aetiology. Estimated prevalence of leg ulceration was determined together with the aetiological classification. One hundred and thirteen patients were identified in a population of 252,000, giving a crude prevalence of 0.4511,000 (0.311,000 in men, 0.511,000 in women). Rates were highly dependent on age, increasing to 8.29 and 8.0611,000 in the over 85's respectively. Of the total, 621112 (55%) had their ulcer for longer than one year, Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs, with a further 21 having ulceration primarily due to arterial disease. Complex aetiologies were present in 48 (35%) limbs, most of whom had venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%). The prevalence of chronic leg ulceration is about one third of that predicted by previous studies using similar methodologies in the 1980's. Patients with ulceration have more complex aetiologies than previously recognised which may be a consequence of both increasing ulcer chronicity and age.
Ischaemic evaluation in the patient bed (ABPI) and (TCP0 2 ) R. Mani When tissue perfusion pressure is inadequate, oxygen demand for cellular nutrition becomes unsustainable. And when this state obtains unrelieved, cell death and eventually ulceration occur. Decrease in perfusion pressure may result from advancing luminal disease in the coronary/peripheral arterial circulation. Local
VOL 15 NO.2 MAY 2005
blockage of the resistance network (embolic). Uncontrolled increase in venous pressure, Inability of the red blood cell to carry oxygen. Changes in rheology. The first clinical sign to be suspect in all these events is the pulse. What objective support is available to detect these changes reliably) Do these objective changes permit patients to be pre-selected for therapy? The objectives of this workshop are to examine the principle physiological changes and widely available methods of measuring these changes. The workshop will address the reliability of the techniques, the ease of use and the clinical significance of tl1eir interpretation.
Use of risk factor scales in pressure ulcer prevention M. Clark Pressure ulcer prevention starts with the identification of those individuals vulnerable to pressure ulcer development. For too long this process has depended upon the use of a wide variety of risk assessment scales or "risk calculators". This presentation will argue that the continued use of risk assessment scales (in their present format) may be counter-productive to successful pressure ulcer prevention. Four specific failings of current risk calculators will be discussed; the lack of agreement over what are true risk factors, the lack of consensus over how risk factors should be combined within a risk tool, the failure to identify that risk calculators predict who may develop pressure ulcers, the links between risk calculator scores and the selection of pressure-redistributing equipment. The presentation will conclude with brief comments upon the future of risk calculators within pressure ulcer prevention highlighting that if these tools are to be retained then significant changes to their construction and use may be required.
Pressure ulcer aetiology - latest concepts D. Bain The basic model for the aetiology of pressure ulcers consists of tissue necrosis resulting from insufficient delivery of oxygen and nutrients to the tissue by the blood. The model becomes more complex as we explore the causes of that hypoxic state. Causative factors may be sub-categorised into direct and indirect factors. Direct factors act upon the body to cause hypoxia. Indirect factors render the body susceptible to the direct factors. This presentation first examines the current understanding of indirect causative factors, considering the proposed mechanisms of causation, and the strength of evidence for each. Direct causative factors are then explored in the same way, Major gaps in our understanding are identified, including the mechanical characteristics of the soft tissues, and quantitative knowledge of the 4-dimensional conditions required to cause damage. Avenues of research are suggested to begin
23
the incidence of non-blanching erythema in a hospital in-patient population (n=23) when compared to the use of the ninety-degree lateral and supine position (n=23). The main findings were that patient positioning using the thirty-degree tilt method did not reduce the incidence of non-blanching erythema compared with either the ninety-degree lateral and supine positions. This study also investigated the feasibility of using the thirty-degree tilt position and identified that subjects experienced difficulty in adopting and maintaining the position. This finding seriously questions the practicality of the thirtydegree tilt method when it is used with a predominantly ill population. The problems encountered in conducting research in the clinical area are highlighted.
Physiological and anatomical indications in pressure ulcers ns. Bain ( Given the validity and reliability problems entailed by risk assessment, a promising adjunct strategy for reduction in ulcer prevalence is offered by diagnostic tools for early identification of incipient ulcers. In current clinical practice, grade 1 pressure ulcers are unreliably diagnosed. Problems include the difficulty in seeing and comparing erythema in different skin types, especially in dark skin, and the variability in subjective assessments. Three approaches for detecting the early signs of pressure ulcers are considered: 1) An objective measurement device based on reflectance spectroscopic principles that examines the volume, oxygenation, and dynamics of blood in the skin. 2) Using NMR parameters to identify early changes taking place deeper in the tissue. 3) Nutritional and biochemical markers. An objective device for assessment of skin condition has the potential to enhance reliability of clinical judgement. This is useful for consistent early identification, and steady tracking of progress, botl1 of which are key to effective management of grade 1 ulcers.
Wound dressings S. Bale The effective use of dressings results from a structured, systematic and logical approach to patient care. This organised approach comprises assessment of patient's needs, the formation of a wound care plan, selection of an appropriate dressing, and evaluation of progress. Assessing patient's needs: Factors that impair the healing process including intrinsic and extrinsic factors; Wound assessment including wound bed, exudate level, wound shape, and wound size; Patient's preferences including lifestyle, ability to work and desire to become involved in wound care; Patient's circumstances including physical environment of home or hospital. Formulating a wound care plan: Investigations needed including Doppler, Xray, blood values and risk assessments; Interventions indicated including wound debridement, cleansing, and
22
compression bandaging. Select a dressing based on these criteria: Alginates; Hydrocolloids; Foams; Hydrogels; Low adherent dressings; Medicated dressings. Evaluate progress: Wound measurement; Charting wound bed health; Time to healing. The aim of this workshop is to demonstrate the role of dressings in managing wounds.
Palliative care S. Bale Carcinomas and sarcomas are the most likely cancers to produce ulceration and fungation in the later stages of the disease. Managing patients with these malignant wounds often presents difficult clinical challenges. The most common type of ulcerating or fungating lesion is' found in women with breast cancer. As the prognosis for healing is usually poor, symptom control and improvement in quality of life are frequently the main aims of care. Managing patients with such complex problems requires a multidisciplinary approach, and typically this team includes the nurse, oncologist, psychologist, and surgeon. It is also important that the patients are encouraged to identify their main problems and that subsequent interventions are decided through a partnership between the clinician and patient. The aim of this workshop is to discuss the care of patient's with complex clinical malignant wound problems. It is important to determine, through a comprehensive assessment, the treatment aims. This usually comprises control of symptoms such as odour, exudate, pain, and also body image. These problems can occur in combination, where wounds are highly exuding, malodorous, bleed easily, and can cause pain' and discomfort. Effective wound management includes the skilful use of dressing materials to cope with the physical problems of odour, bleeding and excess exudate, although the psychological problems are more difficult to deal with.
Nutrition and wounds M. Clark Poor nutrition has often been associated with both pressure ulcer prevention and healing and attention to nutrition is often proposed within pressure ulcer clinical guidelines. However what is the evidence that impaired nutrition increases the likelihood of developing pressure ulcers? This presentation will consider the evidence that impaired nutrition is directly associated with the development of pressure ulcers. The presentation will also consider the limited evidence that improving nutrition can reduce the incidence of pressure ulcers.
Interactive cases in pressure ulcers C. Dealey Management of pressure ulcers can be complex and challenging. It requires a multi-professional approach, particularly for patients who remain at risk of further
VOL 15 NO.2 MAY 2005
pressure ulcers development after the existing ulcer is healed. It is important to identify the causative factors for a pressure ulcer so that they can be removed wherever possible. Management strategies should include a holistic assessment, pressure relief, nutrition, skin care and wound management. Workshop participants will be presented with a number of cases and will be invited to discuss their management.
Epidemiology of venous ulceration P. J Franks Current prevalence estimates of chronic leg ulceration are frequently based on studies undertaken during the 1980's. During the last decade, major changes have occurred in the application of evidence based practice, potentially altering the prevalence and patient characteristics of this group. We have determined the prevalence and aetiology of leg ulceration in a defined geographical population with eight years experience of providing a standardised evidence based protocol of care. Identification, interview and clinical assessment of patients with leg ulceration (>four weeks) within an integrated acute and community leg ulcer service were undertaken. Standardised questionnaire on medical history, ulcer details and non invasive vascular investigation were used to describe aetiology. Estimated prevalence of leg ulceration was determined together with the aetiological classification. One hundred and thirteen patients were identified in a population of 252,000, giving a crude prevalence of 0.4511,000 (0.311,000 in men, 0.511,000 in women). Rates were highly dependent on age, increasing to 8.29 and 8.0611,000 in the over 85's respectively. Of the total, 621112 (55%) had their ulcer for longer than one year, Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs, with a further 21 having ulceration primarily due to arterial disease. Complex aetiologies were present in 48 (35%) limbs, most of whom had venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%). The prevalence of chronic leg ulceration is about one third of that predicted by previous studies using similar methodologies in the 1980's. Patients with ulceration have more complex aetiologies than previously recognised which may be a consequence of both increasing ulcer chronicity and age.
Ischaemic evaluation in the patient bed (ABPI) and (TCP0 2 ) R. Mani When tissue perfusion pressure is inadequate, oxygen demand for cellular nutrition becomes unsustainable. And when this state obtains unrelieved, cell death and eventually ulceration occur. Decrease in perfusion pressure may result from advancing luminal disease in the coronary/peripheral arterial circulation. Local
VOL 15 NO.2 MAY 2005
blockage of the resistance network (embolic). Uncontrolled increase in venous pressure, Inability of the red blood cell to carry oxygen. Changes in rheology. The first clinical sign to be suspect in all these events is the pulse. What objective support is available to detect these changes reliably) Do these objective changes permit patients to be pre-selected for therapy? The objectives of this workshop are to examine the principle physiological changes and widely available methods of measuring these changes. The workshop will address the reliability of the techniques, the ease of use and the clinical significance of tl1eir interpretation.
Use of risk factor scales in pressure ulcer prevention M. Clark Pressure ulcer prevention starts with the identification of those individuals vulnerable to pressure ulcer development. For too long this process has depended upon the use of a wide variety of risk assessment scales or "risk calculators". This presentation will argue that the continued use of risk assessment scales (in their present format) may be counter-productive to successful pressure ulcer prevention. Four specific failings of current risk calculators will be discussed; the lack of agreement over what are true risk factors, the lack of consensus over how risk factors should be combined within a risk tool, the failure to identify that risk calculators predict who may develop pressure ulcers, the links between risk calculator scores and the selection of pressure-redistributing equipment. The presentation will conclude with brief comments upon the future of risk calculators within pressure ulcer prevention highlighting that if these tools are to be retained then significant changes to their construction and use may be required.
Pressure ulcer aetiology - latest concepts D. Bain The basic model for the aetiology of pressure ulcers consists of tissue necrosis resulting from insufficient delivery of oxygen and nutrients to the tissue by the blood. The model becomes more complex as we explore the causes of that hypoxic state. Causative factors may be sub-categorised into direct and indirect factors. Direct factors act upon the body to cause hypoxia. Indirect factors render the body susceptible to the direct factors. This presentation first examines the current understanding of indirect causative factors, considering the proposed mechanisms of causation, and the strength of evidence for each. Direct causative factors are then explored in the same way, Major gaps in our understanding are identified, including the mechanical characteristics of the soft tissues, and quantitative knowledge of the 4-dimensional conditions required to cause damage. Avenues of research are suggested to begin
23